The parents of two babies who died hours after they were born at a hospital trust engulfed in the worst maternity scandal in NHS history have been praised for bringing widespread failings to light.
This morning a damning report by maternity expert Donna Ockenden highlighted how shocking poor care at Shrewsbury and Telford Hospital NHS Trust may have led to the deaths of more than 200 mums and babies, while dozens suffered brain injuries.
In her report Ms Ockenden praised the tireless work of the parents of Kate Stanton Davies and Pippa Griffiths in exposing deadly practices.
Kate died just six hours after she was born in March 2009, while Pippa lived for just 31 hours in 2016.
They are among 201 babies and nine mothers who may have survived had they had proper care, today's report ruled.
At least 94 more babies suffered avoidable brain injuries, while there were at least 304 cases of serious harm.
Praising Kate and Pippa's families, Ms Ockenden said: "This review owes its origins to Kate Stanton Davies, and her parents Rhiannon Davies and Richard Stanton; and to Pippa Griffiths, and her parents Kayleigh and Colin Griffiths.
"Kate’s and Pippa’s parents have shown an unrelenting commitment to ensuring their daughters’ short lives make a difference to the safety of maternity care."
In a letter to health Secretary Sajid Javid, she wrote: "It was through their efforts that your predecessor, the former Secretary ofState for Health Jeremy Hunt requested this independent review.
"When it commenced this review was of 23 families’ cases, but it grew to include reviews of nearly 1,500 families, whose experiences occurred predominantly between 2000 and 2019."
Richard Stanton, whose daughter Kate Stanton-Davies died during birth in 2009, said before the report was published: “This is a watershed moment for maternity care across the NHS.
“SaTH was a horrendous case but they were not an isolated trust. You only have to look in East Kent and Nottingham where hundreds more families are coming forward to express concern about the care they received.
“I hope the police will now have sufficient evidence to present to the CPS for a prosecution.
“SaTH should suspend senior managers who have been promoted or moved sideways. They have overseen the culture of normal births at all costs.”
Richard’s wife Rhiannon Davies gave birth in a midwife-led unit run by the Shrewsbury trust in March 2009 where there were no doctors. She remembers “the midwives encouraged us to go there to ‘keep their numbers up’”.
Pippa Griffiths died aged just 31 hours from a Group B Strep infection April 2016.
Mum Kayleigh says her concerns as Pippa became sicker and sicker were ignored.
The trust later told Kayleigh and Pippa's dad Colin that their daughter's death could not have been prevented.
But the following year a coroner ruled the tragedy was avoidable – and blamed a string of errors by midwives.
NHS auditor Kayleigh said: “We expected better from the NHS. But Pippa was failed.”
Pippa was born in a planned home birth in North Shropshire on April 26 2016.
A midwife said she would return in the afternoon - but never turned up, the court found.
By evening, Pippa’s parents were concerned, as the newborn was “breathing very heavily”, Kayleigh said.
When Pippa began vomiting brown mucus during the night, Kayleigh called the trust at 2.55am.
But the midwife who took the call simply told them someone would be in touch the next day.
“She insisted it was normal.” said Kayleigh. But no midwife visited and instead the couple received a phone call and that midwife also said it was normal.
Kayleigh and Colin discovered Pippa’s skin had turned purple. Then she stopped breathing. They dialled 999 and Pippa was airlifted to hospital.
But despite the “amazing efforts” of emergency medics, she died at 4.09pm on April 27.
Maternity expert Ms Ockenden said "so many parents" said they tried to raise concerns but were not listened to.
She said the "required scrutiny" has now taken place, adding: "The voices of families are now finally being heard."
Ms Ockenden said the review team was particularly concerned by the "lack of transparency internally within the trust, as well as the lack of honesty and transparency shown to families".
She said the review team found "repeated errors in care which led to injury to either mothers or to their babies".
She added: "We have fully reviewed the cases of 12 mothers who lost their lives giving birth at the trust. Seventy-five percent of the cases of maternal death have been graded by our team as categories two and three with significant or major concerns in the care provided.
"Unfortunately, and overall, our report describes that a significant number of mothers and babies received care that fell way below the standards expected and this continued throughout the whole period of the review."
